Filing · f0260

Highmark Medicaid - Pennsylvania

Highmark · Medicaid Managed Care · PA · Jan 1, 2025 - Dec 31, 2025

In 2025 this plan received 22,141 standard prior authorization requests and denied 3.8% of them. The median for Medicaid Managed Care plans of comparable size is 13.2%.

Standard denial rate

3.8%

22,141 standard requests, 850 denied. 34.8% of appealed denials were overturned.

Requests and outcomes

	Total	Approved	Denied	Denial rate
Standard	22,141	21,291	850	3.8%
Expedited	15,156	14,730	425	2.8%
Extended review, approved	764

This payer also printed its own standard denial rate: 4.0%. The rate above is computed from the published counts, so the two can be compared.

Appeals of standard denials

Appeals filed	1,744
Denials overturned	606
Overturn rate	34.8%

Turnaround

	Mean	Median
Standard	1.5 d	—
Expedited	—	—

Source

https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-de/documents/pdfs/prior-authorization-code-lookup/prior-authorization-metrics.pdf

Section heading in the extracted text reads 'State Medicaid & CHIP FFS programs'; Highmark operates as a managed care organization, so coded Medicaid Managed Care - the heading is ambiguous and may mean these rows mix FFS and MCO business. Expedited approved+denied (14,730+425=15,155) is one less than the stated 15,156 total. Standard median and expedited mean/median printed as '<1 day'. Appeal overturn rate 35% is low relative to the MA lines in the same document.

Filing ID: f0260
Published: counts
Collector: blues

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